=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063692945
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALTER J CHLYSTA MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2007
-----------------------------------------------------
Last Update Date | 03/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 WABASH AVE
-----------------------------------------------------
City | AKRON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44307-2433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-344-1100
-----------------------------------------------------
Fax | 330-344-0032
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 WABASH AVE
-----------------------------------------------------
City | AKRON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44307-2433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-344-1100
-----------------------------------------------------
Fax | 330-344-0032
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. WALTER J CHLYSTA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 330-344-1100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 35070064
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------